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Home My WebLink AboutWiring Permit - Correspondence - 25 GREAT LAKE LANE 11/25/2015 f Date ! ..� .... . t F taORT/y 03� TOWN OF NORTH ANDOVER h 9 * * PERMIT FOR WIRING ACHUg� i This certifies that ............................................................................................... has permission to perform ..,.. to r. ..............I...............................I......... ...... wiring in the building of......7-A,_ ..I........... at ....b� ...... �7 s p ;, � Y. North Andover,Mass, .. Fee W=.:.r......G`............Lic No. i... r ,m .'........ ................................ ELECTRICAL INSPECTOR Check# A' erV C `d� e Commonwealth of Massachusetts Official Use Only Permit No. Department of Fire Services Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS IROV-1/071 (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be perforined in accordance with the Massachusetts Electrical Codi(ME9,527 CMR 12.00 (PLEA SE PR WT IN JNK OR TYPE A LL MFORM TION) City or Town of: NORTH ANDOVER To the Ins�ector of Wires: By this application the-undersigned gives notice of his or her intention to perform the electrical work described below, Location(Street&Number) 1 t, k il-4J Owner or Tenant Telephone No. ww Owner's Address 2 a', Is this permit in conjunction with a building permit? Yes ❑ No ❑ (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service— Amps Volts OverheadF] Undgrd n No.of Meters New Service Amps Volts OverbeadF] Undgrd F1 No.of meters Nui.nber of Feeders and Ampacity Location and Nature of Proposed Electrical Work: S2 Completion of the following table may be waived by the Inspector of Wires. No. o No.of Recessed Luminaires No.of Cell.-Susp.(Paddle)Fans Trans Total Transformers KVA No.of Lurninalre Outlets No.of Hot Tubs Generators 1CVA No.of Luminaires Swimming Pool Above o In- N—o.-OTEmergency Lighting grnd. grnd. F1 Battery Units No.of Receptacle Outlets No.of Oil Burners FME ALARMS INo, of Zones of Detection and No. of Switches No.of Gas Burners No. Initiating Devices No. of Ranges No.of Air Cond. Total No.of Alerting Devices Tons Heat Pump JN!jp�h-- 'Tons IKW No. of Self-Contained No. of Waste Disposers Totals: ...................I................ Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local❑El Municipal n Other Connection urity Systems:* No. of Dryers Heating Appliances KW Sec No.of Devices or Equivalent No. of Water No.of No.of Data Wiring: Heaters KW Signs Ballasts . No.of Devices or Equivalent No.Hydromassaae Bathtubs No.of Motors Total HP Telecommunications Wiring: No.of Devices or Equivalent OTHER: Attach additional detail 1fdosired,or as required by the Inspector of Wires. Estimated Value Electrical Work: "0 C)4,1 (When required by municipal policy.) Work to Start: 71,'� t,' Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE COVERAGE: Unless waived by the owner,no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent. The undersigned certifies that such coverage is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE P/ BOND El OTHER El (Specify:) Icertoy', under the tins and penalties qfpeijwy,that the information on this application is true and complete. FIRM NAME: LIC.NO.-414g Licensee: Signature K LTC.NO. ffapplicab7e,Snter "exetWpt"in the license number line.) Bn`i.'-Tel.No.: ��L i2- ,,4 , Address: P� :�y. ,Ir G111 , �.., A-�,4_ e)t S, A5L Alt,Tel.No.:'ZA'2 2- *Per M.G.L c. 147,s.57-61,security work requires Department ofPublic Safety"S"IdGeDSC' Lic.No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below,I hereby waive this requirement. I am the(check one)0 owner []owner's agent. Owner/Agent Signature Telephone No. P UMIT FEE.- The Commonwealth of Massachusetts Department of IndustrialAceidents A t 1 Congress Street,Suite 100 Boston,MA 02114-2017 www.mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE PILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Leizibly Name(Business/Organization/Individual): ; ° , .� Address C) City/State/Zip: ._ . ....; :,. .... Phone#: .. ;�� , "1 .... — Are you ap employer?Check the appropriate box: Type of project(required): I f al am a employer with employees(fidl and/or part-time).* 7• E]New construction 2.�lam a sole proprietor or partnership and have no employees working for me in 8. []Remodeling any capacity.[No workers'comp.insurance required.] 3.Q I am a homeowner doing all work myself,[No workers'comp.insurance required.]t 9. ❑Demolition 10 ❑Building addition 4.Q I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole 11.QAElectrical repairs or additions proprietors with no employees. 12.[]Plumbing repairs or additions 5. I am a general contractor and I have hired the sub-contractors listed on the attached sheet. These sub-contractors have employees and have workers'comp.insurance.$ 13.[�Roof repairs 6.Q We are a corporation and its officers have exercised their right of'exemption per MGL c. 14.❑Other 152,§1(4),and we have no.employees.[No workers'comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. TContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees, if the sub-contractors have employees,they must provide their workers'comp.policy number. lain an employer tfaat is providing ivorlfers'compensation insurance for fny employees.'Beloiv is the policy and job site information. Insurance Company Name: Y p uA . C Stat /Ztm � Folic #or Self-ins,Lic Expiration ate Job Site Address. �.. .�� 1. i (.,�i a�"�'",� a'" .i.. zty/ p ( k,�' _.�,..,i , t i.c � �'_ ,•� � 1 Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA.for insurance coverage verification. ,- �,,, p p Date: and correct. Y .fy„f fp jwy that the information prow e hove is trace I do hereby,certify u der•the pains aaad enalties o ea Sianature: Phone#: as°J Official use only. Do not write in this area,to be completed by city or town official.. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: GENERATOR APPLICATION DATE: LOCATION: Z OWNERS NAME: ..w ::,s , GENERATOR kw NO INSTALLATION OR GROUND DISTURBANCE BEFORE APPROVALS* CONTRACTOR: s . . } .._... -: .. PHONE NUMBER: ELECTRICAL - ' GAS RESIDENTIAL COMMERCIAL TEMPORARY LOCATION OF GENERATOR: ::.__ � `ZONING DISTRICT: s �II� d PLANNING APPROVAL (IF IN WA ERSHED) �� " ° " `CONSERVATION APPROVAL _ O